White Oak Pediatrics


Patient Information
Middle Name
Last Name
 First Name
Date of Birth
 Sex
Responsible for Payment (Guarantor)
First Name
 Middle Name
Last Name        
Sex
Social Security #
Date of Birth
Home Street Address
City,State
Email Address
Home Telephone
Cell Phone
Cell Phone number and E-mail Address are very
important because they allow us to send you
reminders.    
Relation to Patient
Primary Insurance Information
Insurance Company Name
 ID/Policy Number
 Group Number
Policy Holder Name
 Policy Holder
 Policy Holder Date of Birth
Policy Holder Relationship to Patient
Contact (other parent or contact if applicable)
Last Name
 First Name
 Middle Name
Relationship to Patient
Home Street Address
 City, State
Home Telephone
 Work Telephone
 Cell Telephone
Pharmacy Name
 Pharmacy Telephone
Pharmacy information is very important
because allows us to send electronic
prescriptions directly to your pharmacy
I
certify that all of the above information is complete
and accurate and will notify the office of any changes.  I agree that I will be
responsible for the consequenses of innaccurate information (billing wrong
insurance, wrong lab, etc).  I also certify that NO OTHER HEALTH COVERAGE
EXISTS AT THIS TIME OTHER THAN THE ONE ABOVE.  I understand it may be
illegal not to disclose the existence of a health care coverage.  I understand IT
IS MY RESPONSIBILITY TO INFORM White Oak Pediatrics immediately should
a change in health care coverage occur at any time in the future.  I understand
that I am ultimately responsible for all charges whether or not covered by my
insurance.
Date
 Electronic Signature
White Oak Pediatrics